MARINE INVESTIGATION REPORT

M11N0047

STRIKING
SUPPLY VESSEL MAERSK DETECTOR AND
MOBILE OFFSHORE DRILLING UNIT GSF GRAND BANKS
GRAND BANKS OF NEWFOUNDLAND
24 NOVEMBER 2011

The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose
of advancing transportation safety. It is not the function of the Board to assign fault or
determine civil or criminal liability.

Marine Investigation Report

Striking
Supply Vessel Maersk Detector and
Mobile Offshore Drilling Unit GSF Grand Banks
Grand Banks of Newfoundland
24 November 2011
Report Number M11N0047

Summary
On the afternoon of 24 November 2011, the offshore supply vessel Maersk Detector was using
dynamic positioning while loading cargo from the mobile offshore drilling unit GSF Grand
Banks in the White Rose oil field. Weather was deteriorating at the time, with increasing swells
arriving from the south. The vessel did not maintain position and, at 1530:39 Newfoundland
and Labrador Standard Time, the port stern of the Maersk Detector struck the port aft
intermediate column of the GSF Grand Banks, holing both the vessel and the rig. No injuries or
pollution resulted from this occurrence.

Ce rapport est galement disponible en franais.

-3-

Factual Information
Particulars of the Vessels
Maersk Detector

Names of vessels

GSF Grand Banks

Registry/licence number

828347

8752415

Port of registry

St. Johns, Newfoundland and

Labrador

Port Vila, Vanuatu

Flag

Canada

Vanuatu

Type

Offshore Supply Vessel/

Anchor-Handling Tug

Aker H-3.2 semi-submersible

mobile offshore drilling unit
(MODU)

Gross tonnage

5470

15 923

Length 1

89.3 m

77.13 m

Draught

Forward: 6.50 m
Aft: 6.90 m

Forward port: 20.19 m

Forward starboard: 20.09 m
Aft port: 20.13 m
Aft starboard: 20.01 m

Built

Asenav - Astilleros y Servicios

Navales S.A., Santiago, Chile
in 2006

Saint John Shipbuilding and

Drydock Co. Ltd., Saint John,
New Brunswick in 1984

Propulsion

4 MaK diesel engines, (total

power 13 440 kW),
2 controllable-pitch propellers,
4 thrusters

4 Bergen diesel electric engines,

(total power 7596 kW) driving
two 1500 kW azimuth thrusters

Cargo

126 tonnes of oil rig

equipment

3117 tonnes of oil drilling

equipment

Crew

15

90

Registered owners

Maersk Supply Service

Canada Ltd., St. Johns, NL

Global SantaFe Overseas Ltd,

Bahamas

Units of measurement in this report conform to International Maritime Organization

(IMO) standards or, where there is no such standard, are expressed in the International System
(SI) of units.

-4-

Description of the Vessels

Maersk Detector
The Maersk Detector is a supply vessel/anchor-handling tug, classed as an offshore supply
vessel and fitted with a Kongsberg SDP 21 dynamic positioning (DP) system. The vessel is fitted
with 4 main propulsion engines driving 2 controllable-pitch propellers. Each propeller is
connected to an outer engine of 3840 kilowatt (kW) rating and an inner engine of 2880 kW
rating at 600 revolutions per minute (rpm). When DP is active, the engines run at a constant
rpm.

Photo 1. The Maersk Detector (Source: Provincial Aerospace Limited)

The thruster configuration consists of 4 units: at the bow there is a tunnel thruster and
retractable azimuth thruster, each with an 883 kW motor, while at the stern there are 2 tunnel
thrusters, each with 700 kW motors. All thrusters are driven by controllable-pitch propellers
powered by electric alternating current (AC) motors with a constant speed. The vessel is also
fitted with 2 independent Becker rudders. 2 For a general arrangement of the vessel, refer to
Appendix A.
Dynamic Positioning System
A seagoing vessel is subject to forces from wind, waves, and current, as well as those generated
by the vessels propulsion system. The vessels response to these forces (changes in position,
heading, and speed) is measured by the DPs position-reference systems, gyrocompass, and
vertical reference sensors. Reference system readings are corrected for roll and pitch using

A Becker rudder is a proprietary rudder with a hinged flap at the trailing edge to
increase the turning effect.
2

-5readings from the vertical reference sensors. Wind speed and direction are measured by the
wind sensors. Using this data, the DP control system calculates the forces that the thrusters
must produce 3 in order to control the vessels surge, sway, and yaw within 3 horizontal
degrees of freedom relative to the setpoints for heading and position that are inputted by the
DP operator (DPO) (Figure 1). 4

Figure 1. Dynamic Positioning System 5

The DP system on the Maersk Detector was designed to comply with the requirements of the
classification society, Lloyds Register, 6 as well as the International Maritime Organization
(IMO) standards 7 for Class 2 8 DP systems. The system includes the following sensor/input

Because current and wave height are not measured parameters, the DP controller, which
is essentially the DP systems control software, calculates these contributions to overall force
through an extended Kalman filter. As such, the controller cannot compensate immediately for
large changes in these parameters.
3

Kongsberg Maritime SDP, Operator Reference Manual Dynamic Positioning System,

Rel. 5 Update 1, November 2003.

Kongsberg Maritime SDP, Operator Reference Manual Dynamic Positioning System,

Rel. 5 Update 1, November 2003, section 18.3.

Lloyds Register class notation, DP(AA) dynamic positioning system with redundancy
in technical design capable of automatic and manual position and heading control under
specified maximum environmental conditions, during and following any single fault, i.e., 2
independent computer systems, and an independent joystick system as an additional backup.
6

1994.

IMO, MSC/Circ.645, Guidelines for Vessels with Dynamic Positioning Systems, 6 June

A class 2 DP system is designed such that a loss of position is not to occur in the event of
a single fault in any active component or system.
8

-6components: 3 gyrocompasses, 2 motion reference units, 2 wind sensors, 2 differential global

positioning systems (DGPS), 1 relative positioning laser radar system, and 1 high precision
acoustic positioning system.
The main propellers, rudders, and thrusters can be controlled from manoeuvring panels in the
forward and aft bridge control areas. In the aft bridge area, there are 2 identical DP operation
consoles (Figure 2) that each allow the vessel to be controlled in several different modes via
computer software. The DP modes available include the following:
1. Standby mode: a waiting and reset mode in which the system is in a high state of
readiness, but no vessel control commands can be made.
2. Joystick mode: a mode in which the operator controls the movement and speed of the
vessel using the three-axis joystick.
3. Combined Joystick/Auto mode: a mode in
which the operator can select either 1 or 2
of the surge, sway, and yaw axes for
automatic control of position and speed,
while retaining manual control of the
remaining axis.
4. Auto Position mode: a mode in which the
system automatically maintains the
heading and position of the vessel (all 3
axes). The user inputs the initial desired
position setpoint and maximum speed to
use when manoeuvring to the setpoint.
Once the desired setpoint has been
reached, the DP system controls the
thrusters to maintain that setpoint
position.

Figure 2. DP operation console. 9

There are 20 DP console display views of

positioning, mechanical, and power management data that provide the DPO with real-time
values and trends to assist them in maintaining full control of the DP system and ensuring that
the vessel setpoint is safely maintained. For examples of the display views available on the
Maersk Detector DP system, refer to Appendix B. Using these views, operators can derive
information such as the following:
1. The real-time plotting of the vessels position in relation to the selected setpoint;
2. Information about the performance of the reference systems;
3. Detailed information about out-of-position alarms and/or heading alarms;

Kongsberg Maritime SDP, Operator Reference Manual Dynamic Positioning System,

Rel. 5 Update 1, November 2003, section 1.1.

-74. Trends showing the average, minimum, maximum, and standard deviation history over
a specified period for selected information, such as wind, sea current, position and
heading deviation, thruster forces, and power consumption; and
5. Information about the power management of the vessels thrusters.

GSF Grand Banks

The GSF Grand Banks commenced operations off the East Coast of Canada in 1984. It operated
under several different names in various locations around the world until 2003, when it
returned to the Grand Banks area. It is a rectangular, twin-hulled, column-stabilized, non-selfpropelled mobile offshore drilling unit (MODU) or, more commonly, a rig. The rig has 4 corner
stability columns of 9.0 m in diameter as well as 4 intermediate stability columns of 7.4 m in
diameter rising from 2 hulls to support the main deck. The deck is arranged with the drilling
mast in the centre and modules housing the living quarters, equipment, storage area, and
workshops on the perimeters.

Photo 2. GSF Grand Banks showing the Maersk Detector on the port side. (Source:
Marine Aerial Reconnaissance Team Atlantic)

Crane Operations
On the GSF Grand Banks, the port crane is mainly used for general cargo transfers. This type of
cargo is usually stowed on the port side of the rig, as the starboard deck area contains the drill
test packages and, as such, is limited in space.

-8The rig port crane operating limits are 45 knots wind or 4 m significant waves. 10 The crane
operator has an anemometer readout for wind speed in the crane cab and periodically calls the
rig ballast control room (BCR) for wave heights. Earlier on the day of the occurrence, the deck
foreman had called the BCR for wave heights and was aware that the significant wave height
(Hs) 11 was 3.2 to 3.6 m.
The port crane can boom down to a maximum reach of 44.9 m but is usually at a set limit of
39 m reach, which ensures at least 5 m reach is available to chase the vessel with the crane hook,
if needed. The crane is also fitted with a main/auxiliary winch emergency load release which,
when activated, allows both the main and the auxiliary winches to go into an uncontrolled freefall, releasing the load.
The starboard crane cannot reach most of the cargo stowed on the port side. As a result, the
cargo must be moved within reach of the starboard crane using the port crane. This means that
2 crane lifts are required (1 with each crane) for each lift of cargo when loading a vessel on the
starboard side. For this reason, the starboard side is only used when the port side is unavailable
and the cargo is critical for the continuity of the drilling operation.

History of the Voyage

On 14 November 2011, the Maersk Detector departed St. Johns, NL and proceeded to the GSF
Grand Banks, which was moored on 8 anchors and engaged in drilling operations on the Grand
Banks of Newfoundland at the White Rose oil field operated by Husky Oil Operations Limited,
(Appendix C). The Maersk Detector arrived at the field on 15 November to provide standby and
supply vessel services.
At approximately 0615 12 on 24 November, the first officer safety (FOS), 13 who was on watch,
advised the master that they had received a request to proceed alongside the GSF Grand Banks
to load synthetic base mud and deck cargo (containers and pipe). The FOS then completed the
DP checklists and prepared for the cargo operation.
During the daily morning meeting on board the GSF Grand Banks at 0630, the rig supervisors
discussed ongoing and planned operations for that day. During the routine oil field operators
meeting at 0700, Husky representatives, rig supervisors, and the weather observer reviewed the
ongoing and planned drilling/marine operations and discussed the weather forecasts and
present weather conditions. The planned cargo operation was considered routine.

GSF Grand Banks Operating Manual, Cranes, Section 1.11.1., published by Global
Santa Fe., revision 2 dated 27 June 2003.

10

Significant wave height (Hs) is the mean wave height of the highest third of the waves in
a 30 minute period.

11

All times are Newfoundland and Labrador Standard Time (Coordinated Universal Time
[UTC] minus 3.5 hours), unless otherwise stated.

12

The crew of Maersk Detector included 2 first officer positions: First Officer Safety (FOS)
and First Officer Navigation (FON).

13

-9On the Maersk Detector, at about 0700, the master came onto the bridge. The vessels request to
enter the 500 m safety zone 14 was approved by the BCR and at approximately 0736, the vessel
entered the 500 m safety zone. About 10 minutes later, the vessels DP Auto Position mode was
activated.
At 0806, the vessel was stationed on the lee side 15 of the rig on an easterly heading with its port
side positioned to the port side of the rig to load the mud and cargo. These operations
continued until approximately 1150, when the vessel moved outside the 500 m safety zone to
allow the Maersk Chancellor, another supply vessel arriving on site, to go alongside the rig and
offload its cargo.
At 1200, the first officer navigation (FON) took over the bridge watch. The FON then completed
the appropriate checklist and assumed the role of DPO while the vessel was at the outside edge
of the 500 m safety zone waiting for the Maersk Chancellor to complete its operation.
At about 1250, the FON completed the appropriate checklist, switched from DP Auto Position
to DP Joystick mode and re-entered the safety zone as the Maersk Chancellor exited. At
approximately 1300, when 100 m from the rig, the DP was changed to Auto Position mode and
the FON used position/heading change inputs to move closer to the rig.
At about 1315, the Maersk Detector was about 15 m off the lee side of the rig on a heading of
122true (T) (Appendix D, Figure 1) and around 1330 commenced loading containers on deck.
Between 1330 and 1400 the wind shifted from a northerly to the southeasterly direction, with
the rig port side changing accordingly from lee side to weather side. 16 There was no formal
briefing or risk assessment conducted for this weather-side operation.
During the cargo operation, the wind and sea state veered, and was now coming more from the
south. The master discussed the weather situation with the deck foreman, who was operating
the port rig crane, and they agreed to stop operations when conditions became unsuitable. 17
Minor changes of heading were made to keep the wind on the port bow of the vessel as it
moved from a lee side to a weather side condition.
At approximately 1400, the relative positioning laser radar system was added as a third position
reference for the DP system by the crew. By 1430, the vessels heading had been changed to
140T and the wind was about 45off the starboard bow as loading operations continued
(Appendix D, Figure 2). Around 1445, the master completed the appropriate checklist and took
over the DP operations from the FON. The FON remained on the bridge as officer of the watch
(OOW), watching the cargo operation and making relevant log entries from a position next to

A safety zone is the area that extends from the outer perimeter of the rig to the greater of
500 m in all directions and 50 m beyond the boundaries of the anchor pattern of the vessel.

14

15

The lee side of the vessel is the side that is sheltered from the wind.

16

The weather side of the vessel is the side towards the wind.

The weather forecasts received at 0600 indicated that the conditions for operation would
worsen later in the day (sometime between 1430 and 2030).

17

-10the master. The master then did a capability analysis 18 using the current wind conditions and
an input of 5 m Hs. The results indicated that the vessel could maintain position, using DP Auto
Position mode, on any heading. The FON moved to the port aft chair and took charge of the
loading operation using channel 6 very high frequency (VHF) and ultra high frequency (UHF)
radiotelephones to communicate with the rig and deck crew as necessary.
By 1500, the vessels heading had been changed to 160T, putting the wind at around 25 off the
starboard bow (Appendix D, Figure 3). The master contacted the BCR, using channel 6 VHF
radiotelephone, to obtain the sea state information. The master was informed that the Hs was
3.5 m.
At about 1510, the driller in the break room on the rig observed the vessel through a window
and notified the offshore installation manager (OIM) 19 that the Maersk Detector appeared to be
too close to the rig. The OIM called the barge supervisor 20 who then went to check the vessels
position. The barge supervisor then spoke to the crane operator and was informed that the
vessel appeared to be maintaining a safe distance. The barge supervisor remained on deck to
observe the vessel for about 10 minutes. He then relieved the ballast control operator (BCO) in
the BCR to take a break and notified the OIM that the vessels position was appropriate. The
OIM relayed this information to the driller.
At approximately 1510, the Husky Logistics representative, who was on the rig, called the
master to discuss the weather conditions and advised him that the Hs was 3.5 m. The wind
speeds at that time were around 20 knots and the seas were getting larger. They concluded that
the operation could be terminated at any time by the master if warranted by the weather
conditions.
At 1522, the last container was loaded onto the vessel and pipe was to be loaded next. The
master inputted the change position and heading commands to move the vessel off the rig, and
then altered the heading by 20 to starboard to better load the pipe on the stern. At about 1524,
the heading was approximately 180 and more directly into the swell (Appendix D, Figure 4).
The master changed the bow thruster azimuth setting from fixed abeam (90 relative) to
variable stabilizing.
For the next 6 minutes, the master continued as DPO. As the vessel pitched and heaved from an
increasing southerly swell, the master was focused on looking out the aft window to judge the
distance from the stern to the rig. The FON, the only other person on the bridge, continued to
watch the crew on deck and make log entries. The master then used channel 6 VHF

The objective of a DP capability analysis is to determine the limiting environmental

conditions (wind speed, wave height, and current) within which the vessels thrusters will be
able to maintain position and heading while using DP.

18

19

OIM.

The function of the rig and performance of all personnel are the responsibility of the

The barge supervisor holds a Masters certificate of competency and is responsible for all
marine operations on board, including navigation and cargo transfers.

20

-11radiotelephone to advise the deck foreman, who was operating the crane, that the vessel was in
position and ready to be loaded.
At about 1529, the crane was swinging the first lift of pipe over the vessel. At that time, there
was a distance of about 15 m between the port stern of the vessel and the port aft intermediate
column of the rig. Shortly after, while experiencing the next 5 swells, the vessel began to move
astern at an average speed of about 0.4 m/s. During the fourth swell, the master attempted to
increase the vessels distance from the rig by entering a 4 m change position command using
the DP console. However, the vessel continued to approach the rig column. At 1530:39, the
vessel struck the rig, breaching the port aft intermediate rig column and the vessels port stern
aft peak tank.
At that time, a shudder was felt on the rig; closed circuit television (CCTV) monitors were
checked, but there was no indication of what caused the shudder. The barge supervisor called
the crane operator and was informed that the vessel had struck the rig. The barge supervisor
then called the vessel and was told to standby. A minute or so later, the vessel advised it had
struck the rig above the waterline; a second call followed shortly after to advise that both the rig
and vessel were holed. The barge supervisor advised the OIM and then began supervising the
damage control team. The BCO was requested to deballast the rig from a draft of 22 m to 19 m
to stop the ingress of water into the breached column. The vessel immediately moved off the rig
about 15 to 20 m, and the crew disconnected the pipe slings from the crane hook. At about 1539,
the Maersk Detector proceeded to the south of the rig and changed from DP to manual bridge
control.

DP Proving Trials
On the 04 and 05 December, a DP proving trial of the Maersk Detector was conducted in the
waters off St. Johns, NL. This trial was performed to test the redundant capability of the system
by simulating the failure(s) of various components and to prove that the DP system was fully
functional and well maintained. The reports of this trial show that the Maersk Detectors DP
system met all relevant criteria and there were no indications of any problems or issues with the
system that may have affected the station-keeping of the vessel.

Damage to the Vessels

The Maersk Detector was holed on the port stern, and 3 frames buckled in the number 23 ballast
tank (Photos 3 and 4), resulting in the release of fresh drill water into the ocean.
The GSF Grand Banks was holed in an empty void tank on the port aft intermediate column just
below the 27 m watertight flat in way of the aft end of the fendering system (Photo 5). The rig
was deballasted about 3 m in draft to stop the ingress of water. The tank was about 11.25 m in
depth and was filled to about 0.4 m prior to deballasting.

-12-

Photo 3. Area of damage on the Maersk Detector. 21

Photo 4. Close-up of damaged area. 22

Photo 5. Location of damage to GSF Grand Banks. (Source: Provincial

Aerospace Limited)

Crew Certification and Experience

The master and navigating officers all held the required certificates of competency for their
positions. The master held a Master Mariner certificate of competency, was formally trained in
DP operation and held an unlimited DP operator (DPO) certificate issued by the Nautical

21

Screenshot of rig video courtesy of Transocean Ltd.

22

Ibid.

-13Institute based in the United Kingdom. He had 26 years of experience on supply vessels, with
10 of those years as a master. He served as master on the Maersk Detector for 4 years; for 2 of
those years, he acted as senior DPO when required.
The FON held a Watchkeeping Mate certificate of competency. He was also formally trained in
DP operation and held an unlimited DPO certificate issued by the Nautical Institute based in
the United Kingdom. He had 4 years of experience as first officer with Maersk, including 2
years on the Maersk Detector. For 1 of these years he acted as a junior DPO when required.

Vessel Certification
The vessel was crewed and equipped in accordance with existing regulations and held valid
certificates issued by Lloyd's Register on behalf of Transport Canada (TC).

Environmental Conditions
Weather Forecast
The marine weather forecasts were issued by a shore-based company to the rig and the supply
vessels. The forecasts issued at 0600 and 1200 indicated that the Hs would increase throughout
the day, reaching a measurement of 3.3 m at 1430 and 4.9 m at 2030. The forecasts also predicted
10 m mean wind speeds 23 of 32 knots at 1430 and 21 knots at 2030, with the wind direction at
1430 coming from the south (180) and shifting to the southwest (220) at 2030.

Weather Measurements
There is a directional waverider buoy positioned 2.83 nautical miles (nm) north-northeast from
the GSF Grand Banks that provides wave measurements. Raw wave data is transmitted about
every 1.6 seconds from the buoy to the wave data receiving station located on the bridge of the
rig. The rig and the vessel also both use anemometers to monitor and record wind speed and
direction.
According to the data, between 1430 and 1500, the wind direction shifted from about 192 to
202, with the wind speed increasing to 20 knots. Between 1500 and 1530, the wind direction
varied from about 200 and 205, with the wind speed varying between approximately 18 to 24
knots. From 1500 to 1600, the wave period is estimated to be approximately 8 seconds 24 and the
3 highest wave heights recorded at the waverider buoy were 9.47 m at 1507, 8.72 m at 1544 and
9.62 m at 1546 (Figure 3).

The global standard is to measure wind speed at a height of 10 m (33 ft) above the
earths surface.

23

Waves with a period of about 8 seconds were observed on the CCTV at the time of the
occurrence.

24

-14-

Figure 3. Wave height measured by waverider buoy between 1500

and 1600. 25

As the waves were coming from the south, the waverider buoy recorded the wave heights after
they had been experienced at the rig. The travel time of a wave with an 8-second period from
the rig to the waverider buoy is approximately 14 minutes. 26 If the waves maintained their
characteristics throughout, then the measurement of the waves at the buoy would be indicative
of the waves experienced at the rig 14 minutes earlier. The wave heights of 8.72 m and 9.62 m
were measured at the waverider buoy 14 and 16 minutes after the striking occurred. It is
therefore possible that one or more similar waves were experienced by the vessel immediately
before it struck the rig.

Compilation and Communication of Environmental Information

The raw data received from the waverider buoy is automatically compiled at the weather
station on the rig, which is operated by 1 weather/ice observer. In the weather station, the wave
viewer displays the Hs and the Hmax. 27 The Hs is updated every 200 seconds, while the Hmax
is updated every 30 minutes on the hour and half hour. On the day of the occurrence, the
waveviewer displayed the following Hs and Hmax at the indicated times:

25

Data courtesy of Husky Oil Ltd.

The speed of a group of waves can be measured with the following formula: gT/4
with g = 9.81 m/sec2 where T represents the period of the wave in seconds. Using this formula,
a wave with a period of 8 seconds would travel at a speed of approximately 6.25 m/seconds.
The distance between the rig and the waverider buoy is approximately 5250 m. Thus, the total
travel time for a wave to transit that distance is approximately 14 minutes.

26

27

Maximum single wave height (Hmax) measured during a 30 minute period.

-15Table 1. Hs and Hmax data available from wave viewer at rig weather station.
Time of compilation

1359

1429

1459

1529

Hs (m)

3.16

3.51

4.14

4.50

Hmax (m)

4.71

6.53

6.57

9.47

The weather station operator prepares and then emails meteorological reports (METAR) every
hour at the half hour to recipients that include the Husky environmental department, Husky
Logistics coordinator on the rig, and Husky Logistics office in St. Johns, as well as the rig BCR
and Cougar Helicopters. The METAR sent out by the operator around the time of the
occurrence are provided in Table 2. The operator typically prepares the METAR ahead of the
scheduled transmission time. When viewing both tables, note that at 1429 and 1529/1526 there
is a smaller discrepancy between the Hs values than there is between the Hmax values. This
difference is due to the fact that the Hs is updated more frequently than the Hmax.
Table 2. Hs and Hmax data sent by weather station operator.
METAR transmission time

1331

1429

1526

Hs (m)

2.8

3.4

4.4

Hmax (m)

4.0

4.7

6.6

Weather information is also available on the rig via the mooring advisory system (MAS)
computers in various locations including the BCR, OIM office, Husky office, and on the bridge.
The MAS receives the weather data from the rig weather station and updates the Hs every 30
minutes. When the BCO receives a request for the sea state, the reading can be taken from the
MAS display. On the day of the occurrence, the MAS display in the BCR indicated the following
Hs values:
Table 3. Hs data on MAS display in BCR.
Time on MAS display in BCR
Hs (m)

1438

1508
3.5

1538
4.15

4.5

Helicopters are restricted from landing on the GSF Grand Banks when the Hs reaches 6 m. At
that height, in the event of a helicopter emergency ditching, it becomes difficult for Fast Rescue
Craft (FRC) to rescue personnel in the water. As such, the operator of the weather station must
notify Cougar Helicopters dispatch in St. Johns when the Hs reaches 6 m. There is no similar
procedure when a weather limit for cargo operations is reached.

Voyage Data
Voyage Data Recorder
Various modes of transportation use the data from voice and data recorders to support an
investigation into an accident or incident. In addition to bridge audio, a voyage data recorder
(VDR) is designed to record such parameters as date and time; vessel heading, position and
speed; VHF radiotelephone communications; radar images; engine and thruster orders and
responses; and wind speed and direction measurements.

-16The Maersk Detector was equipped with a VDR, although one is not required for the voyage
undertaken. Following the occurrence, VDR data from the Maersk Detector was recovered by
TSB investigators. The charts in Appendix E and F present some of the data pertinent to the
investigation that was retrieved and interpreted for a 10-minute time period leading up to and
including the striking. 28 Review of this data indicated the following:
1. At around 1524, the thrust output of the azimuth thruster stabilized significantly; at the
same time, the steering parameter began to fluctuate. This is consistent with the master
switching the azimuth control from fixed to variable steering.
2. Once adjusted for the motion of the GSF Grand Banks, the data for distance between the
stern of the Maersk Detector and the centre of the rigs port aft intermediate column
(distance to pylon centre on the chart) exhibited high-frequency oscillations with a
period of about 8 seconds. This was because the position data recorded by the VDR
included the movement of the GPS antennae and therefore reflects the motion of the
vessel about its own axis (primarily pitching in waves) as well as the increase and
decrease in the vessels distance from the rig.
3. The data for the 6.5 minutes prior to the striking also exhibited a low-frequency
oscillation that reflected the movement of the vessel towards and away from the rig
during this time.
4. Between approximately 1529:30 and 1530:00 (30 seconds), the distance between the rig
and the vessel appeared to stabilize, after which it began to steadily decrease while
experiencing 4 complete high-frequency oscillations, primarily due to pitching in waves.
It reached a minimum at approximately 15:30:39, the time of the striking.
5. At approximately 1530:16, after the vessel began its final movement towards the rig, the
data for thrust produced by both the main engines and the azimuth thruster increased
sharply. This thrust acted to propel the vessel away from the rig and reached a value of
less than 5 percent of maximum for each main propeller and less than 40 percent of
maximum for the azimuth.
6. At approximately 1530:35, there was a brief interruption, or dip, in the forward thrust
after which it increased sharply again, reaching a peak value of less than 5 percent for
each main propeller and just over 40 percent for the azimuth.
7. The VDR data for the longitudinal thrust components and distance from the vessel to
the rig are 180 out of phase with each other.
When the data from the VDR was retrieved, the investigation found that the bridge audio data
was corrupted and unusable due to a VDR software error. The manufacturer was already aware
of this VDR software error, and on 21 June 2011 had issued a mandatory Technical Advisory
Sheet No. 379, requiring that a software update be performed at the next annual performance
test. On the Maersk Detector, this test was scheduled for December 2011.

Details regarding the retrieval and interpretation of raw data from the VDR may be
found in the TSB Engineering Report LP116/2012 (available upon request).

28

-17-

Electronic Chart Display and Information System

The Maersk Detector was fitted with an Electronic Chart Display and Information System
(ECDIS). The ECDIS download was used to confirm the positioning data and timeline provided
by the VDR data.

Dynamic Positioning Logger

The DP logger is a software tool used to record data related to the operation of the DP system
and subsequently to retrieve, inspect, transform, and archive that data. In this occurrence, the
logger was operational but not recording. The logger had been installed in May 2011 and had
stopped recording data following a routine software reboot in July 2011, as it was not set to
automatically restart after reboot. At the time the logger was installed, the crew was advised
that the equipment would operate in the background with no operator input required. There
was no manual for the DP logger on board.

Dynamic Positioning Panel Log

When the DP system is operated, messages are sent from the operator panel to a panel driver
that distributes them to the appropriate components of the DP system. The panel driver also
receives messages from the DP system and sends them to the operator panel. In this occurrence,
the Maersk Detectors DP system was configured to log the messages to and from the operator
and the system, for example, the activation of buttons, changes in lamp status, use of the
joystick, and use of the heading wheel. The DP manufacturer service personnel use this
information to analyze problems with the DP system. Following the occurrence, the DP panel
log was downloaded by a manufacturers technician and sent to its head office for
interpretation. The results returned to the TSB did not include data for the period of time of the
occurrence. Panel log data for DP computers OS1 and KM-OS ended at 1425:18 and 1329:44
respectively. The manufacturer could not determine why data was not available around the
time of the occurrence.

Dynamic Positioning System Warnings and Alarms

Operational checks are continuously carried out during DP system operation. There are 3
categories for messages based on their severity: information, warnings, and alarms. Information
messages inform on conditions that are noteworthy, but that have no serious effect on the
performance of the system. Warnings are visual indicators only and provide information on
conditions in the system that, if ignored, could result in unwanted system response or eventual
failure (such as incorrect operator actions, intermittent position-reference data, or a defined
warning limit that has been exceeded). Warnings continue until acknowledged by the operator.
Audible and visual alarms are generated when conditions are detected that critically affect the
capability or performance of the system (system fault or a defined alarm limit that has been
exceeded). These alarms continue until acknowledged by the operator. Audible alarms,
however, may be silenced independent of acknowledgment.
Warning and alarm limits for position and heading deviations can be set by the operator. When
such an alarm or warning is activated, the position deviation indicated by the system is for the
time the warning/alarm was issued; however, the actual deviation can increase after the alarm
and this will not be indicated on the alarm printout. The DP operator could determine the
maximum deviation by continuous monitoring of the appropriate view on the DP console and

-18reviewing the historical trends view for the vessels position. On the Maersk Detector, as a
standard practice, the warning and alarm thresholds were set by the crew at 3 and 5 m
respectively for position, and 3 and 5 respectively for heading.
There was also a warning displayed on the console when thrust exceeded 80% for 5 seconds on
the main propellers or thrusters. This warning would be cancelled when the thrust stayed
below 80% for 20 seconds.
Another scenario in which a warning may be activated is when the difference between the
position data from the reference system(s) and the vessel position estimated by the DP software
model exceeds a user-defined limit. This may be due to an error in the reference system or its
interface to the DP system, or due to environmental disturbances (air/sea). When this happens,
the reference prediction error warning is activated and the data from the reference system
involved is rejected. The operator must then verify that the test rejected the correct reference
system by analyzing the DP reference systems streaming 29 data and historical trend views. If
the system rejects the wrong reference, the model might follow a failed reference position. In
this occurrence, the limit was set at 5.7 m.
The warnings and alarms logged by the DP system on the Maersk Detector between 1315 and
1531 are summarized in the following table:
Table 4. DP System Warnings and Alarms.

Time period
Scenario

Time

Vessel
operating
on lee
side of rig

39 min

Wind
shifts;
vessel
operating
on
weather
side of rig

88 min

Final
heading
change to
180

6.58
min

Events
Alarms
(Pos/Hdg)

Warnings
(Pos/Hdg)

Warnings
(Thruster)

Warnings
(Ref
Prediction)

TOTAL

1 event
every 4.3
min

10

59

75

1 event
every 1.2
min

1 event
every 0.73
min

(1315 to
1354)

(1354 to
1522)

(1524 to
1530:35)

Average
frequency

Streaming is to transfer or transmit (data) in such a way that it is processed in a steady

and continuous stream.

29

-19After the striking, at 1533:27, the DP system logged an information message, consequence
analysis stopped. Consequence analysis is a function whereby the DP system continuously
checks its redundancy. 30 For the Maersk Detector, a consequence analysis stopped message
indicates that the system had been switched from full Auto Position mode to full or partial
Joystick mode or that consequence analysis had been deactivated by the DP operator.

Husky Offshore Service Vessel Guidelines

Husky Oil Operations Limited manages and supports the White Rose oil field using the
established logistics infrastructure and resources in St. Johns, NL. The Maersk Detector had a
copy of the Husky Offshore Service Vessel (OSV) guidelines on board at the time of the
occurrence. The purpose of these guidelines is to give offshore service vessel owners, vessel
masters, and crews guidance on Husky Atlantic Region OSV operations. The guidelines clearly
state that the master of a vessel has the overriding authority to decide whether any operation
affecting the safety and integrity of the vessel or the safety of the crew should proceed or be
suspended.
The OSV guidelines indicate that the vessels crew should obtain regular and frequent weather
forecasts and use their experience to assess the prevailing conditions and probable trends. A
weather-side operation is defined as a situation in which any combination of environmental
forces, such as wind, waves, swell, wave drift, surface current, surge current, tidal current, as
well as changes in those factors, could move the vessel towards the installation. 31 The OSV
guidelines for weather-side operation specify the following precautions:

20-25 knots mean wind speed at 10 m levelSecure loose items and advise greater
caution to prevent injury to personnel and damage to equipment.

Above 25 knots mean wind speed at 10 m levelOperations cease.

3-4 m HsThe OIM, crane operator, and master should assess the situation on
positioning and cargo handling before arrival within safety zone.

Above 4 m HsOperations cease.

Above 50% propeller and/or thruster utilizationOperations cease.

The guidelines stipulate that a risk assessment shall be completed prior to any weather-side
operation due to the risk posed by a vessel that is unable to maintain its position and pushed
onto the installation by environmental forces. The assessment process should help the master
decide the appropriate measures to take and would include the identification of the potential
hazards, their severity and likelihood, the associated risk levels, additional risk reduction

Redundancy refers to the vessels ability to maintain its position and heading, as
prescribed in the classification society standards, should there be a system failure.

30

International Marine Contractors Association, M 182 Rev. 1, Guidelines for the Safe
Operation of Dynamically Positioned Offshore Vessels, 2009.

31

-20measures to continue the operation, and a reassessment to confirm that the remaining risks are
within acceptable limits.
The guidelines stipulate that the risk assessment is to be approved by the master and forwarded
to the rig OIM for review. Upon agreement between the master and OIM, work may resume
according to the conditions stated in the risk assessment. Completed risk assessments are also to
be forwarded to the vessel operators shore management and Husky Energy. Although the risk
assessment for weather-side operations on the Maersk Detector was required to be completed by
around 1400 due to the change in wind direction, the assessment was not done.
The OSV guidelines also stipulate that the operational status of any vessel operating in DP
control should be monitored continuously. This requires that a method be established on board
to alert the crew and relevant personnel to changes in the vessels DP operational status. The
method must reference the established status levels defined by the industry, as follows:
1. Green alertNormal operational status where DP performance is within safe working
limits.
2. Yellow alertDegraded DP operational status when safe working limits are being
exceeded or a non-critical excursion of heading or position is likely.
3. Red alertDP emergency status where there is loss of position or position loss is
inevitable.
From approximately 1354, when the wind shifted, the Maersk Detector was operating in a DP
yellow alert status, which changed to a red alert status in the final 30 seconds before the
striking. However, there was no system in place on board to categorize or communicate this
status.

Dynamic Positioning Capability Analysis

In order to provide vessel owners, operators, and crew with information regarding the ability of
a vessel to maintain its position and heading, it is standard practice for a DP capability analysis
to be performed. 32, 33 This process uses static calculations to compare the total environmental
load with the available thrust power, including a 20% dynamic reserve. The results of this
analysis may be presented in the form of polar plots, each of which are produced for a given
thruster configuration and show the theoretical limiting wind speed, from all directions, below
which the environmental forces on the vessel can be counteracted by thrust. 34

Marine Technology Society Dynamic Positioning Committee, DP Operations

Guidance, Part 2, Appendix 3 Logistics Vessels, version 2.0, 31 July 2012.

32

International Marine Contractors Association, Guidelines for the Design and Operation
of Dynamically Positioned Vessels, IMCA M 103, Rev.1, 1 December 2007.

33

DP capability analysis cannot be used to indicate position deviation due to wave

induced movements.

34

-21The manufacturer of the DP system for the Maersk Detector performed such a DP capability
analysis in 2004. The resulting polar plot can be seen in Appendix G, indicating the following
notable results: 35
1. The overall theoretical limiting wind speed is 33.2 knots from directions 110 and 250,
corresponding to waves with a significant height of 4.7 m.
2. The theoretical limiting wind speed for winds coming from 20 off the bow (as on the
day of the occurrence) is 65.6 knots, corresponding to waves with a significant height of
10.1 m.
In addition to the theoretical capability analysis described above, the DP system on the Maersk
Detector incorporates an online capability analysis function. On the day of the occurrence,
shortly after 1445, the master used this function to test the capability of the vessel should the Hs
increase to 5 m. The results of this check were positive. At the time this check was performed,
the vessel was heading 140 with winds of about 20 knots at about 50 to 60 off the starboard
bow. The capability plot in Appendix G indicates that, with winds from this direction and with
all thrusters operational, the theoretical limiting wind speed is 40 knots, corresponding to
waves with a significant height of approximately 5.5 m.
A means used to verify the adequate functioning of a DP system is the in-service footprint plots.
These are plots of the vessels position while operating under DP in actual environmental
conditions and thruster configurations. The excursion distances 36depend on many factors, one
of which is wind or wave/swell induced movement. Table 5 below summarizes those examples
of past footprint plots for the Maersk Detector that were developed in environmental conditions
and thruster configurations similar or worse than those on the day of the occurrence. Although
a footprint plot was not prepared on the day of the occurrence, relevant data for that day is also
presented for the purpose of comparison (Appendix H).

These results assume that all thrusters are operational and that the waves and current
are from the same direction as the wind.

35

36

Excursion distances refer to the distance the vessel travels from a fixed setpoint.

-22Table 5. Sample Footprint Plots for the Maersk Detector

Vessel
heading
Occurrence

180

Footprint (a)

175

Footprint (b)

168

Footprint (c)

Footprint (d)

Wind speed
(knots)

Wind
direction

1824 200 (20 off

stbd bow)

Seas/Swell

Max
excursion
recorded

4.5 m (Hs)

15 m (aft)

Unknown

4 m (fwd)

3035 148 (20 off

port bow)

Unknown

3.9 m (aft)

168

3540 150-160 (8 to
18 off port
bow)

Unknown

2.7 m (fwd)

300

28 335 (5 off
stbd bow)

2.5 m

1.5 m (port)

35 178 (3 off
stbd bow)

Bridge Resource Management

Bridge resource management (BRM) is the effective management and use of all resources,
human and technical, available to the bridge team to ensure the safe completion of the voyage.
BRM includes workload management, problem solving, decision making, teamwork, and
situational awareness, especially during critical operations. Specifically, bridge team members
have a responsibility to maintain overall situational awareness as well as be responsible for
their individual duties. Furthermore, since a team must work together toward a common goal,
the exchange of information is necessary for the team to be effective. 37 Poor communication can
result in a crew not sharing a common understanding of a situation.
In this occurrence, neither the master nor FON had completed any formal BRM training. TC
does not require bridge officers to complete BRM training to achieve or maintain their
certificates of competency, although they do set standards for non-mandatory BRM training. 38
However, TC is planning to amend the Marine Personnel Regulations (MPR) with respect to BRM
requirements of the Convention on Standards of Training, Certification and Watchkeeping of Seafarers
(STCW) and subsequent Manila Amendments in 2010. The planned TC amendments would
mean that BRM competencies and knowledge would be required to obtain a Watchkeeping
Mate certificate of competency and, secondly, the TC-approved STCW BRM training course
would be mandatory to obtain the following certificates of competency:

M. R. Adams, Chapter 9: Teamwork, Shipboard Bridge Resource Management, Noreaster

Press, July 2006.

37

Transport Canada, TP13117, Training Program in Bridge Resource Management, Revision

01, September 1999.

38

-23

Master Mariner

Master, Near Coastal

Master 3000, Unlimited

Master 3000, Near Coastal

Chief Mate

Chief Mate Near Coastal

Outstanding Board Recommendations

In 1995, the TSB published its report, A Safety Study of the Operational Relationship between Ship
Masters/Watchkeeping Officers and Marine Pilots. 39 The objective of this study was to identify
safety deficiencies associated with teamwork on the bridge, including communication between
marine pilots and masters/officers of the watch. The report raised safety concerns related to the
implementation of effective BRM by bridge teams and made the following recommendations,
which have not yet been found Fully Satisfactory: 40
The Department of Transport require that the initial training syllabus for all ship officers be
modified to include demonstration of skills in Bridge Resource Management.
(M95-09)
The Department of Transport require that all ship officers demonstrate skills in Bridge
Resource Management before being issued Continued Proficiency Certificates.
(M95-10)
In January 1996, TC stated in its response to these recommendations that it will promote the
development and provision of BRM training courses and that there can be a requirement for
prior completion of such a course once they are available in Canada. TC further indicated that
such a requirement would be phased in depending on the certificate of competency held by the
candidate. The responses to both recommendations have been assessed as Satisfactory Intent by
the Board. 41

Analysis
39

TSB Marine Investigation Report No. SM9501.

A Fully Satisfactory rating is assigned if the action taken will substantially reduce or
eliminate the safety deficiency.

40

A Satisfactory Intent rating is assigned if the planned action, when fully implemented,
will substantially reduce or eliminate the safety deficiency. However, for the present, the action
has not been sufficiently advanced to reduce the risks to transportation safety.

41

-24-

Events Leading to the Striking

While the Maersk Detector was loading cargo from the rig GSF Grand Banks, the wind direction
veered as expected, putting the vessel on the weather side of the rig. When this happened, the
vessels ability to maintain position degraded, as indicated by the increased frequency of
heading and position warnings/alarms.
When the vessels heading changed to 180 for the final cargo operation, this significantly
altered the masters visual perception of the distance between the vessel and the port aft
intermediate rig column as it increased the sighting distance and viewing aspect of the column
from the bridge. Furthermore, the pitching of the vessel changed the amount of water that was
visible behind the stern; at times, little or no water would be visible, and at other times the
entire distance between the stern and the rig column would be visible. As such, it would likely
have been very difficult to maintain an accurate judgment of the distance by visual observation.
The master then began repositioning the vessel for the final load, towards a position 15 m off
the rig. For approximately the next 5 minutes, the voyage data recorder (VDR) data indicates
that the distance between the vessel and rig was increasing and decreasing in an oscillatory
manner (Appendix E). At around 1529, the master advised the crane operator that he was in
position and ready to load.
The VDR data at around the same time indicates that the vessel settled into a position for about
30 seconds. However, when viewed in context of the trend over the previous 5 minutes, the
vessel was actually at the peak of a movement away from the rig. After the 30-second period,
the vessel began to move towards the rig again.
Between 1524 and the time of the striking, the alarm log identified 5 position-out-of-limits
warnings and 2 alarms. In addition, the dynamic positioning (DP) system registered reference
prediction error warnings with both GPS just prior to the striking. The operation continued
throughout without any reassessment of the ability to maintain the vessel position within the
alarm limit. The master continued to work outside the alarm limits, as some of these alarms
were induced by position change commands that he had input. The master prioritized his
visual assessment of distance over the alarms issued by the DP system, which were indicating
that the vessel was not maintaining its position well.
The VDR data further shows that just before 1530 when the pipe loading operation started, the
available thrust was acting forward to push the vessel away from the rig. At the same time, the
vessel began to move towards the rig. As the vessel approached the rig, the appearance of the
stern moving up and down in relation to the rig column would have become more pronounced.
Both this change in appearance and the ongoing positioning of the first pipe onto the deck
captured the masters attention and impacted his ability to monitor the DP consoles. Despite
having entered a command to change position by 4 m forward, the vessel continued to move
astern. Because the pipe on the deck was still attached to the crane, the master decided not to
take manual control to avoid the possibility of pulling down the crane. The amount of forward
thrust applied by the DP system in these final seconds was insufficient to counteract the forces
acting to push the vessel astern and the vessel struck the rig.

-25-

Dynamic Positioning Capability

Examination of available information regarding the station-keeping ability of the Maersk
Detector indicates that the vessel would be able to maintain its position within the prescribed
limits. This is supported by the following:

Theoretical capability analysis indicated that the vessel thrusters should have had
sufficient thrust to maintain position in the conditions prevailing at the time of the
occurrence;

Post-occurrence trials confirmed that the DP system was functioning in accordance with
all relevant criteria and there were no indications of any problems or issues with the
system that may have affected the station-keeping of the vessel;

Leading up to the occurrence, the vessel thrust applied was less than 5 percent for the
main propellers and less than 40 percent for the azimuth thruster, indicating that there
was significant reserve thrust; and

Immediately after the striking, the vessel quickly returned to a position of about 15 m
away from the rig in auto-position mode and maintained this position as the lift was
disconnected. The thrust used to achieve this was less than 5 percent for the main
propellers and just over 40 percent for the azimuth.

Nonetheless, for a period of approximately 6 minutes prior to the striking (after the heading
change to 180) the station-keeping of the Maersk Detector was unsteady, with the VDR position
data exhibiting the vessels oscillatory motion towards and away from the rig. The final
movement of the vessel towards the rig could therefore be expected. Furthermore, the VDR data
for thrust and separation distance were 180 out of phase with each other. This is indicative of a
coupling effect whereby the operator input (in this case the DP control system or the master) is
driving the motion of the vessel into an undesirable state. The investigation considered the
following factors as possible causes of this coupling effect:

After the heading change, the waves were acting to push the vessel astern and the DP
model may have been in the process of adjusting to compensate for this.

The effect may have been induced by the master entering position move commands on
the DP console as he attempted to steady the vessel in a favourable position for the cargo
operation. The multiple alarms and warnings on the DP system may have caused the
master to input these position change commands, or, conversely, may have been caused
by these commands.

In addition to the above, several other factors were considered as possibly having
contributed to the striking:

the VDR data showed a momentary dip in forward thrust at 1530:35;

the possibility that one or more large swells were experienced by the vessel immediately
before it struck the rig; and

-26

the positioning accuracy of the vessel reference systems had deteriorated just prior to the
striking as indicated by the reference prediction error warnings noted on the alarm
log.

The investigation was unable to conclusively determine the extent to which any of these factors
may have influenced the motion of the vessel; however, they may have contributed to the
vessels inability to maintain a position off the rig.

Bridge Resource Management

In order to maintain overall situational awareness, it is critical that members of the bridge team
know the masters intentions and inputs if they are to offer timely advice or observations. This
can be achieved with an initial briefing followed by regular exchange of information between
members of the bridge team, including the master. The need to maintain situational awareness
and thus to practice effective teamwork and communication between bridge team members is
equally important when operating in DP mode as when navigating in the conventional sense.
This principle is recognized in industry standards which state that, When operating a DP
system, the key DP personnel should not only be competent and experienced with the vessel,
but able to work together and communicate effectively. 42
In this occurrence, the master was primarily operating the DP system while the first officer
navigation (FON) was acting as the officer of the watch (OOW) and was monitoring the cargo
operation from a position next to the master; there was a bridge team of two. In the increasing
seas occurring after the weather veered, frequent position and heading alarms and warnings
were registered by the DP system. However, in the final minutes before the striking, the
masters attention was more focused on visually monitoring the distance from the rig and he
did not fully review and assess the DP positioning data, warnings, and alarms. Meanwhile, the
FON continued watching cargo operations without maintaining any awareness of the DP
system.
According to the principles of good bridge resource management (BRM), despite each crew
member having a primary duty, that duty should not prevent them from maintaining
awareness of the others activities and working as a team. In this occurrence, however, the
master did not inform or discuss his actions at the DP console with the FON, nor was this
requested by the FON. The result was that the vessels positioning data streaming on the DP
displays was not being adequately monitored.
This absence of effective BRM delayed recognition that the conditions were deteriorating and
the vessel was at risk of striking the rig, preventing the bridge team of the Maersk Detector from
taking adequate evasive action. They did not sufficiently use the information provided at the
DP consoles and did not work as a team to help ensure that the vessels distance from the rig
was maintained.

42

IMCA, M117 Rev. 1, The Training and Experience of Key DP Personnel, 2006.

-27As demonstrated by this occurrence and others, 43 shortcomings in the implementation of BRM
principles have been a factor contributing to marine accidents. However, there is no regulatory
requirement in Canada for bridge officers to complete training or demonstrate continued
proficiency for BRM as a prerequisite to achieve or maintain certificates of competency. In this
occurrence, BRM training/proficiency was also not required by the company, nor had the
bridge team undertaken it voluntarily. In the absence of formal training and continued
proficiency in the principles of BRM, there is an increased risk that bridge team awareness will
be impaired, thereby increasing the risk to the vessel, its complement, and the environment.

Risk Assessment for Cargo Operations

The completion of a risk assessment serves to increase the awareness of all involved of the
potential risks associated with an operation and review or identify mitigating measures. It
provides the crew an opportunity to objectively review, discuss, and remind themselves of the
risks of a particular operation and the control measures that could or should be put into effect
as well as the appropriate response measures to take if an accident or incident were to occur.
Between 1330 and 1400 the rig port side changed from lee to weather side, requiring the master
to complete a risk assessment in accordance with the operators Offshore Service Vessel (OSV)
guidelines. However, a risk assessment was not completed by the bridge team, nor was it
requested by the rig.
The master did take some steps to assess environmental conditions and the vessels capability:

Around 1450, the master initiated a capability analysis of the DP system and the result
indicated that the vessel could maintain position on any heading in the existing weather
conditions at the time, but with a significant wave height (Hs) of 5 m;

The master contacted the rig to obtain Hs information; and

The master discussed cargo operations with Husky Logistics and the possibility of
stopping operations.

The crew did not consider using the starboard side for cargo operations once it became the lee
side and continued loading on the port side with the agreement that they would cease
operations if the conditions worsened. This decision is indicative of plan continuation bias,
which may occur when a person or team continues with a plan although conditions have
changed to an extent that would not have necessarily been acceptable if they had been present
at the beginning of a task.
Another approach may have been to cease loading, move further from the rig, and undertake
the required risk assessment, which would have permitted the crew to institute specific risk
control measures that may have mitigated the increased risk of continuing the operation.

TSB Investigation Report Nos. M97W0197 (Raven Arrow), M00C0053 (AlgoEast),

M05L0205 (Cast Prosperity and Hyde Park), M09C0051 (Federal Agno) and M09W0193 (Petersfield).

43

-28-

Communication of Weather Information

With larger swell heights from the south, the master inquired about the significant wave height
(Hs) by contacting the ballast control officer (BCO) at around 1500. The master was informed
that the measurement was 3.5 m. The BCO had 2 references to provide this information: the
meteorological reports (METAR) emailed at 1429 indicating 3.4 m, and the mooring advisory
system (MAS) screen which indicated 3.5 m. However, at 1459, the weather observers station
on the bridge of the rig was indicating an Hs of 4.14 m. The MAS screen in the BCR was
updated with this value at 1508. The METAR emailed to the BCR at 1526 indicated that the Hs
had increased to 4.4 m.
In this occurrence, the limit of 4 m Hs for weather-side cargo operations had been reached at
least 30 minutes before the striking. This information was available at the weather station and in
other areas on the rig 44 at least 20 minutes before the striking. However, when the limit was
reached, it was not communicated to the vessel and crane operator; rather, they were required
to request this information.
When environmental limits are in place, they must actively be monitored and communicated as
soon as possible to all personnel tasked with operational decision making. The weather
observer on the rig proactively informs helicopter operators when weather limits for helicopter
operations at the rig are reached. In the absence of a similar procedure for marine cargo
operations, the vessel and crane operator were unaware that the Hs limit had been reached and
the loading operation continued.

Dynamic Positioning Status Procedures

In critical DP operations where tolerances are low, such as a vessel maintaining position near an
offshore installation, a key element of risk management is the awareness of all involved of the
vessels station-keeping status. This element is recognized in industry standards that require
continuous monitoring of the vessels operational status during DP operations with a means to
alert all crew and personnel involved when the status changes.
Although required by the OSV guidelines, there was no system in place on the Maersk Detector
for categorizing or communicating the vessels status while DP was active. At no time during
that day was the crane operator or rig advised that the vessel was experiencing a
DP station-keeping alert status even though numerous warnings and alarms were evident on
the vessels DP event log. The crane operator and rig were only advised after the striking.
In this occurrence, there was time available for coordinated action between the crane operator
and the vessel to be taken, including emergency release of the lift, which may have avoided the
striking. As evidenced in this occurrence, the absence of a well-established and practiced
procedure for communicating emergency or warning messages, as well as the corresponding
actions to be taken, increases the risk that key personnel will not be fully aware of an
emergency, act in isolation, and make ineffective decisions.

The mooring advisory system computers are located in the BCR, the Offshore
Installation Manager (OIM) office, the oil field operator office, and the bridge.

44

-29-

Voyage Data
The purpose of a VDR is to create and maintain a secure, retrievable record of information
indicating the position, movement, physical status, and control of a vessel for the period
covering the most recent 12 hours of operation. Objective data is invaluable to investigators
when seeking to understand the sequence of events and identify operational problems and
human factors.
In this occurrence, the VDR audio data was corrupted and unusable due to a software error.
Furthermore, the DP data logger and panel log data was unavailable. This data would have
benefitted the investigation by establishing all the control inputs made by the DP operator and
those undertaken autonomously by the DP system. When electronic data, in this instance VDR
audio data and DP data recording, are not available to an investigation, identification and
communication of safety deficiencies to advance transportation safety may be precluded.

-30-

Findings
Findings as to Causes and Contributing Factors
1. At the time the master advised the crane operator that the vessel was in position and
ready to load, the vessel, which had been oscillating towards and away from the rig, was
at the peak of a movement away from the rig. Subsequently, the vessel began another
movement towards the rig.
2. The master gave priority to his visual assessment of distance and position over the
dynamic positioning (DP) systems alarms and warnings, which were indicating that the
vessel was not maintaining its position well.
3. Although the vessel had sufficient reserve thrust available, the amount of forward thrust
applied by the DP system in the final seconds was insufficient to counteract the forces
acting to push the vessel astern, and the vessel struck the rig.
4. The investigation could not explain conclusively the vessels movement and inability to
maintain a position off the rig. Both may have resulted from a combination of the
following: the interaction between the operator and the DP system, a brief dip in
forward thrust just prior to the striking, the possible effects of one or more large swells,
and the deterioration of the positioning accuracy of the vessel reference systems.
5. The bridge officers did not work as a team, nor did they make full use of the data
available on the DP consoles in order to maintain the vessels distance from the rig.
Consequently, their awareness of the imminent striking was delayed, and this prevented
adequate evasive action from being taken.
6. The crew did not perform a risk assessment of the weather-side operation and continued
loading cargo without taking specific risk-control measures. Such measures might have
mitigated the increased risk associated with the weather-side cargo operation.
7. Because there was no procedure for providing relevant weather information to marine
operators proactively, the vessel and crane operator did not know that the significant
wave height (Hs) limit requiring termination of operations had been reached, and the
cargo operation continued.

Finding as to Risk
1. The absence of a well-established and practised procedure for communicating and
responding to emergency or warning situations increases the risk that key personnel will
not be fully aware of an emergency, act in isolation, and make ineffective decisions.
2. When voyage data, such as bridge audio and DP data recordings, are not available to an
investigation, identification and communication of safety deficiencies to advance
transportation safety may be precluded.
3. In the absence of formal training and continued proficiency in the principles of bridge
resource management, there is an increased risk that bridge team awareness will be
impaired, thereby increasing the risk to the vessel, its complement, and the
environment.

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Other Findings
1. Wave measurements from the waverider buoy near the occurrence location indicate that
it is possible that waves of 8.72 m and 9.62 m in height were experienced by the vessel
around the time of the occurrence.

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Safety Action
Safety Action Taken
The TSB was informed that Maersk Supply Service Canada Ltd. has implemented the following
changes:
1. All bridge officers on board Maersk Detector on both shifts have received bridge resource
management training.
2. Shortly after the occurrence, a Safe Job Analysis (SJA) DP Operations which included the
Husky Offshore Service Vessel (OSV) guidelines was developed and implemented.
3. All SJA's pertaining to DP operations and working alongside have been updated to
reflect the findings in the investigation report.
4. The data logger manual has been placed on board the Maersk Detector. Some training is
being provided to the crew to ensure that it is turned on and logging DP data.
5. The Kelvin Hughes voyage data recorder (VDR) software on board Maersk Detector was
updated on 6 December 2011 during the annual performance test (APT) of the VDR.
6. Maersk Supply Service has incorporated stop work triggers into its risk assessment for
DP operations and DP procedures to respond to emergency and/or warning situations
on OSVs operating in DP.
The TSB was informed that Husky Oil Ltd. has implemented the following changes:
1. All vessels operating on behalf of Husky have direct access to the weather service
provider's website to ensure continuous up-to-date weather forecasting (including sea
heights) is available at all times.
2. A Husky Activity Specific Operating Guideline has been implemented. The guideline
was developed by a third party DP Assurance Company by incorporating industry best
practice and offshore operating guidelines.
3. Husky has implemented annual DP competency assessment and training requirements
to be completed on vessels by a third party DP Assurance Company. This will ensure
continued education in DP operations, industry best practice, and guidelines for
offshore DP operations.
4. Husky completed information sessions with OSV contractors to clearly outline
expectations while operating in the White Rose field. These sessions included clear
explanation of DP alarm limits and required actions when alarms are activated.
5. Husky and its contracted drill rig operator developed a 500 m zone work practice to
ensure continuous communication, monitoring of work environment, and clearly
defined roles of offshore installation managers for rig and vessel interactions.
6. A presentation was delivered to other basin operators to share insight and lessons
learned from the incident.
TSB was informed that Canada - Newfoundland and Labrador Offshore Petroleum Board
(C-NLOPB) has implemented the following changes:

-331. The C-NLOPB also requested that the Marine Operations Manual, Safety Case, and
Emergency Response Plan for the GSF Grand Banks be updated. These requests are being
actioned by Transocean Ltd.
2. In July and September 2012, the C-NLOPB safety department conducted marine
operations audits on board both the Henry Goodrich and the GSF Grand Banks, which
included a review of supply vessel operations.
3. Recommendations for improvements and/or corrective actions such as training, updates
to standing orders and procedures, maintenance of marine equipment, etc. were
generated from these audits and are being implemented.
This report concludes the Transportation Safety Boards investigation into this occurrence. Consequently,
the Board authorized the release of this report on 06 March 2013. It was officially released on 09 April
2013.
Visit the Transportation Safety Boards website (www.bst-tsb.gc.ca) for information about the
Transportation Safety Board and its products and services. You will also find the Watchlist, which
identifies the transportation safety issues that pose the greatest risk to Canadians. In each case, the TSB
has found that actions taken to date are inadequate, and that industry and regulators need to take
additional concrete measures to eliminate the risks.

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Appendix A General Arrangement of the Maersk Detector

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Appendix B Dynamic Positioning Console Screen Displays

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Appendix C Area of the Occurrence

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Appendix D Positions of Maersk Detector and GSF Grand

Banks

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Appendix E Voyage Data Recorder Data

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Appendix F Longitudinal Forces and Vessel Position

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Appendix G Dynamic Positioning Capability Plot with All

Thrusters Active

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Appendix H Footprint Plots

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